Provider Demographics
NPI:1033292842
Name:JACKSON, LINDA L (MAED, LPC, CGP, NCC)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MAED, LPC, CGP, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1960 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-3104
Mailing Address - Country:US
Mailing Address - Phone:336-727-0504
Mailing Address - Fax:336-748-0720
Practice Address - Street 1:2735 HENNING DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4578
Practice Address - Country:US
Practice Address - Phone:336-727-0504
Practice Address - Fax:336-748-0720
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC949101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional